With the recent publicity concerning the physician assisted suicide of Brittany Maynard, maybe it’s time to take a look at euthanasia in more detail. I’m going to use this post to start off a short series on euthanasia.

The word “euthanasia” is supposed to derive from the Greek “euthanatos” (εὐθανασία) usually translated as “a gentle death” or “a good death.” As such, someone who dies painlessly from natural causes or artificial causes can have experienced euthanasia. But generally, we think of euthanasia as a process that is carried out by a human (or human agency.) Someone takes an overdose of a medication with the intent of committing suicide. Or, if a legal execution is carried out painlessly, it can be classed as euthanasia.

Brittany Maynard

Brittany Maynard

Suicide is somewhat different. In cases of suicide, the victim and no one else, is the actor and the method chosen can be without regard to whether there will be pain involved. The suicide carries out his demise totally by his own hand via whatever means available: shooting, a staged “accident,” poisoning, hanging or using other methods. So some suicides can be a form of euthanasia, depending on the setting and the means selected.

Euthanasia can also be subclassified as follows:

• Voluntary euthanasia – the person is mentally competent, informed of his outcomes and choices and desires that his life be ended humanely.

• Non-voluntary euthanasia – the person has not expressed the desire to die and is unable to make an informed choice (e.g. someone who is mentally incapable of understanding and making such a choice: an infant, someone who is mentally retarded, someone who is insane, etc.) In this instance, euthanasia is offered because the patient is terminally ill, may have unrelieved pain, may have a very poor quality of life, etc. An example might be an infant who is terminally ill, whose suffering is unable to be relieved whose parents give consent.

• Involuntary euthanasia – the person has made an informed choice to refuse assistance to die (e.g. a condemned criminal who opposes his sentence.) Involuntary euthanasia, other than lawfully performed by a government, is legal everywhere.

The above can be further subdivided into “active” and “passive” forms of euthanasia.

• Active euthanasia is considered the administration of some substance that acts to kill (e.g. a lethal injection.)

• Passive euthanasia is withholding something that could be necessary to support life in some patients. Examples would be not starting antibiotics for an infection in a terminally ill patient, not initiating IV fluids and nutrition in a dying patient unable to eat, etc.

Since we’re not talking about a gentle death from natural causes we need to look at how euthanasia can be carried out.

Technically, euthanasia can be performed by the patient himself, or the patient can be passive and someone else acts to end his life (either at his request, or otherwise.) The patient may act completely on his own, planning and executing his death. Or he may collaborate with someone else who aids him with his plan. In the first case, the patient might use some previously prescribed medications to end his life acting solely on his own. Or he might ask his spouse or a friend to provide some of his/her medications and use them for the same end. These are instances of voluntary euthanasia.

Of course, in the instance of capital punishment, the government will provide and administer the drugs without any action on the part of the condemned (involuntary euthanasia). Something similar could be done in a form of non-voluntary euthanasia.

Under the above definitions, Brittany’s suicide would be a voluntary euthanasia where others helped her to carry out her wishes. That subclass of euthanasia has come to be known as “assisted suicide (AS) or “physician-assisted suicide (PAS.)” I’d argue that, since the methods chosen for these types of suicide are painless, they’d be more appropriately called “assisted euthanasia” or “physician-assisted euthanasia” rather than suicide.

For the most part, AS and PAS are forms of voluntary euthanasia where the patient requests that someone else assists him to end his life. That is, the patient must rely on someone else to supply the means to his end. A physician, family member, pharmacist, etc. who provides medications that the patient can use to overdose. Or to supply him with some other means with which to commit suicide. In these instances, the patient still retains control and administers the medication or makes use of other means himself. That is, the process is both patient-directed and patient-controlled.

Brittany Maynard on her wedding day.

Brittany Maynard on her wedding day.

Looking back into the history of euthanasia, we can view the work of Dr. Jack Kevorkian a physician who was a pathologist. He was very interested in death and later in his career, advocated for euthanasia. He acted acted as a “death consultant.” He allegedly would advise a terminally ill patient about different methods of suicide. Then, if the patient wanted to proceed, Kevorkian would set up one of two machines that he constructed. One would administer a lethal injection of drugs intravenously when the patient pushed a button. The other would release carbon monoxide gas into a mask placed over the patient’s face, again when the patient pressed a button. In these circumstances, the patient took his own life with a degree of external assistance. So Brittany’s suicide was also assisted in that respect. She obtained the drug combination that she used from an Oregon physician.

Many people think that euthanasia has to be done with medications: sedatives, opioids, tranquilizers or other drugs. While that i.e. often the case, there are other methods of euthanasia that are available. As I mentioned above, Dr. Kevorkian made use of a lethal gas instead of a pharmaceutical.

Euthanasia/AS isn’t an option for most people in the world or in the US. It is prohibited in most places. That’s why Brittany had to leave San Francisco to move to Oregon. Oregon is one of the few states which has a “death with dignity” (or similarly titled) law that allows for a patient to be able to end his own life. Oregon, Montana, Vermont, Washington and New Mexico permit assisted suicides under certain circumstances. In no state is it legal for anyone, physician or other person, to directly administer euthanasia. The patient must do that himself.

Countries that permit euthanasia are: Luxembourg, the Netherlands and Belgium (here, the physician administers the euthanasia agent.). Assisted suicide (where the patient takes his own life) is legal in Switzerland, the Netherlands and Luxembourg.

Child euthanasia is legal in Belgium. In the Netherlands, it is technically illegal for children under 12 years old. However, those following the “Groningen Protocol” will not be prosecuted.

Most states and countries that allow either lawful euthanasia or assisted suicides have very strict guidelines concerning how they can be carried out.

Places that allow euthanasia or assisted suicide have rigid requirements that must be adhered to whether for euthanasia or AS/PAS. Some of these include the following (though the requirements may vary by location):

That the patient be terminally ill. That has usually come to mean that the patient is expected to have six months or less of life left. Though, realistically, it can be impossible to predict this. In Brittany’s case, she was initially told that she might live a few years. Later that estimate was drastically reduced. Yet she still outlived the expectations placed on her.

There may also be a phrase included in the law saying something like the patient must have “intractable suffering” from some disease. That often means cancer as the cause of the suffering , but there are also other diseases that would qualify. Severe heart disease, advanced pulmonary diseases and others are possibilities that might fulfill the “intractable suffering” requirement.

The patient may be required to undergo psychological testing to make sure that he is capable of understanding his choice. This also allows for the examiner to judge if the patient is suffering from some form of mental illness or depression that might influence him unduly.

Often the patient must make his request in writing, request assistance with suicide more than once, see at least two different physicians who both agree that this patient is one who is appropriate for assisted suicide.

This is a brief overview of a broad and controversial topic. In the remainder of the series, we’ll look at some other aspects of euthanasia/AS/PAS that need to be considered in a topic as important as this is.

This article, and the ones that follow, are meant to provoke a discussion, both here on AMERICAblog and elsewhere. A discussion that will allow people to express opinions and ideas on euthanasia and assisted suicide and, perhaps, lead to encouraging the public to take a look at euthanasia, AS and PAS in a different light. Possibly this might lead to legislative changes.

Mark Thoma, MD, is a physician who did his residency in internal medicine. Mark has a long history of social activism, and was an early technogeek, and science junkie, after evolving through his nerd phase. Favorite quote: “The most exciting phrase to hear in science... is not 'Eureka!' (I found it!) but 'That's funny.'” - Isaac Asimov

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12 Responses to “Euthanasia”

  1. Silver_Witch says:

    We are all dying day-by-day. The choice to die today is a right that should not be decided by the state or another human. If I choose to make today the last day I should have that right -without the stigma of “suicide”. Thank you for saying it so much better than me nicho.

  2. hidflect says:

    I had a girlfriend who was a nurse in the oncology ward of a very big and internationally respected hospital in Perth, Western Australia. She told me that they involutary-euthanize people all the time there. Practically daily. I scoffed, telling her that if that was the case then it would’ve hit the media years ago. There would have been a massive scandal, surely. She told me that they know. Everybody knows. The politicians, journalists, immediate staff, everybody who’s anybody.

    She described people lying on their bed unable to be rotated for bedsores because they’ll break open and foul, dark fluid will pour out of their rupture. The cancer having already eaten the consciousness out of their brain leaving them moaning and wailing periodically like an animal in constant pain because the morphine doesn’t work anymore.

    Most often, she said, it’s the family who beg for “relief”. So when you read the obits about some child who dies of cancer they say something like, “.. and little Susie passed away quietly in her sleep..” Damn right. O.D.’d with enough morphine to kill a buffalo is another way of putting it. The oncology ward is heavily sealed off from the rest of the hospital and the risk of infection is only part of the reason.

    My GF used to come home crying many nights and she was as tough as nails. She used to bitterly joke about how oncology nurses got an extra $50/week over other nurses for the hardship of the role. Like it was a joke, or something. I asked her, “What about the super-religious people?”. She replied, “They’re the worst.” I never got an explanation of what she meant but I guess they were the most compliant to the idea of passing their kith and kin onto a “better world”.

    So. IF this hospital does it.. you can bet thousands of others worldwide do it from Tokyo to Tacoma. The rest is just conversation we all have like twittering birds on the periphery.

  3. Blogvader says:

    It boggles my mind that end-of-life decisions are in any way regulated by the state. The decision to end one’s life, by whatever means they prefer under any circumstances they choose, should be considered a fundamental right in my opinion.

  4. mf_roe says:

    This is fricking settled law, Roe v. Wade established the principle that life belonged to the person that contained it,not the STATE. ASSHAT Pro Lifers have never been able to touch that. They have undermined the delivery system but the Mother still has the Right. Since preservation of life isn’t an issuse Medical personell are not required. Pay for a termination license purchase a drug cocktail take your leave

  5. mf_roe says:

    Establish precedent :
    1 Life Liberty Pursuit
    2 US has authority to revoke. rights
    3 US’ power derives from consent
    4 Consent can be withdrawn by citizen–in good standing (Unlike States)
    5 the right to renounce citizenship includes the right to renounce your life

  6. Indigo says:

    I understand the need to focus discussion on medical issues for socio-political reasons. And that’s likely to work. Meanwhile, on a larger scale, the issue is actually resolvable on the individual level, no permissions are required. The horns of this dilemma, and I agree that we’re not on opposite sides of the question, is that in order to cultivate nationwide agreement on euthanasia in the case of terminal illnesses, a certain limit applies to the discussion.

    But among the opposition to that apparently reasonable medical line of thought, are the “slippery slope” responses. And therein . . . well, you already know what I think. Yes, it’s fine, it’s an individual’s decision. “My life, my decision.” There’s no question the resistance gets upset at that point. And there’s not a whole lot to be said in response to them other than to point to the diversity of our culture.

  7. nicho says:

    I agree wholeheartedly. I don’t think we’re on opposite sides. But I think we need to separate the issues to inject clarity. If we start talking about suicide under non-terminal conditions and join the two issues, than we may lose a lot of supporters for ending life in terminal situations. It’s just a matter of keeping similar, but distinctly different, matters separate.

    If we get people onboard for end-of-life decisions for terminally ill people, then we’ve move the discussion forward and may begin to rational discuss those decisions under non-terminal conditions. The arguments there, as well as cautions needs, the checks and balances, etc., are completely different.

  8. Indigo says:

    Of course, but that’s not the entire picture. There are an amazing number of recent reports of suicides triggered from harassment and bullying that might have been prevented under better, more understanding circumstances. And there are the impulsive suicides of people angry or confused over issues meaningful to them. But there are also perfectly rational suicides that are decisions to check out, as the old-fashioned expression goes, that are economic or personal or even emotional. And there’s no external criterion that demands the life must always wind its way to end “naturally,” as you phrase it, outside of some religious teachings that might apply to believers but not beyond that realm. It does not confuse the issue to understand that euthanasia as a medical decision is one of many possible end of life formats.

  9. nicho says:

    You’re absolutely right, but the question of deciding to end your life for reasons other than imminently terminal illness, what we would call “rational suicide,” is another whole discussion, and it’s best not to confuse the two. Otherwise, you end up in shouting match that goes nowhere. One thing at a time.

    I think that generally you will find more people in favor of a terminally ill person deciding to end his/her life than you will for someone who decided to end his life just because he decided it was too burdensome to go on.

    In the first case, it’s not a decision to die — that decision is already out of your hands. All you’re choosing is the means and the time. In the latter case, you are deciding to end your life when it would not have ended naturally had you not acted.

  10. Indigo says:

    Both demonizing the vocabulary and gilding the vocabulary confuse the issue. Maybe the word “usually” is the sticking point for me here. Suicide can be an entirely sensible decision, given medical or economic or personal issues that are meaningful to the individual []. In some cases, legal sanction exists. In other cases, not. I’m thinking of several friends over the years whose HIV infection reached the point where self-euthanizing was the path they chose.

    Yes, suicide, sometimes with a gun, other times with pill-and-alcohol. And that can be sensible. If advancing this discussion is important enough to choose our words carefully, then it is also wise to avoid the Pollyanna trap our society has set up, that suicide is always somehow disgusting and wrong. Honorable seppuku might be archaic but it is honorable. In pre-Christian days, ancient Romans chose suicide over defeat in battle or politics.

    Admittedly, those are examples drawn from other times but my point is that our times are the ones that are tainted with quibbles. We need to sort them out and set them aside. “My life, my decision,” is the best rule of thumb I can offer.

  11. nicho says:

    One thing that’s necessary for the debate to go forward is to detach the word “suicide” from assistance in dying. While it technically is suicide (killing yourself), usually we think of a person who commits suicide as someone who would have otherwise lived, maybe a long life and chose to die because of despair, depression or some other treatable condition. In making choices about taking control of dying, we’re dealing with people who are dying. It’s no longer a question of “if,” but a question of when and how.

    But because we conflate the two concepts, it muddies the waters. This is why anti-choice activists refer to abortion — no matter how early in the development of the organism as “killing babies.” It muddies the water — and that’s their intention.

    Anyone who wants more information could find it at:

    Compassion and Choices

  12. Hue-Man says:

    • Involuntary euthanasia – the person has made an informed choice to refuse assistance to die (e.g. a condemned criminal who opposes his sentence.) Involuntary euthanasia, other than lawfully performed by a government, is legal everywhere.

    NOT EVERYWHERE. Headline: “Treating a child’s cancer is not an abuse”

    “In similar cases, where parents have refused life-saving medical interventions for religious reasons (such as Jehovah’s Witnesses refusing blood transfusions) or because they reject mainstream medicine for whatever reason, the courts have been quick to intervene and compel treatment.

    But in this case, the court decided that the parents’ aboriginal rights take precedence over the life, liberty and security of an individual child. A judge’s role is often to find the proper balance
    between conflicting rights; in this case, the scales of justice tipped the wrong way.”

    Canada will join the right-to-die list within the next year. Quebec has enacted legislation which hasn’t yet been implemented. It’s complicated because crime (here, murder) is a federal responsibility whereas health (i.e. health and doctors) is a provincial responsibility.

    “More than three quarters of Canadians support the Supreme Court of Canada’s ruling last week legalizing physician-assisted suicide, according to a new Forum Research poll.

    The survey of 1,018 adult Canadians conducted Monday and Tuesday, after Friday’s unanimous decision by the top court, found 78 per cent of respondents favour the ruling.”

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